ADAPtAção Do moDElo ABCDE PArA ComunICAr A má notíCIA Ao ProPrIEtárIo Do PACIEntE ONCOLÓGICO EM MEDICINA VETERINÁRIA
ADAPtAtIon oF thE ABCDE moDEl From humAn mEDICInE to CommunICAtE BAD nEWS to thE OWNER OF THE ONCOLOGIC PATIENT IN VETERINARY MEDICINE
ADAPtACIón DEl moDElo ABCDE DE mEDICInA humAnA PArA ComunICAr mAlAS notíCIAS A lo DUEñO DEL PACIENTE ONCOLOGICO EN MEDICINA VETERINARIA
Helena Vala1,2
Fernando Esteves1
Ana Cristina Mega1,3
Carla Santos1
Carmen Nóbrega1
João Mesquita1,4
1Instituto Politécnico de Viseu, CI&DETS, ESAV, Viseu, Portugal
2Centro de Investigação e de Tecnologias Agro-Ambientais e Biológicas (CITAB), Portugal;
3Universidade de Coimbra, Faculdade de Medicina, Instituto de Imagem Biomédica e Ciências da Vida (IBILI), Laboratório de Farmacologia e Terapêutica Experimental, Coimbra, Portugal
4 Universidade do Porto, Centro de Investigação em Biodiversidade e Recursos genéticos, CIBIO/UP, Porto, Portugal
Helena Vala - [email protected] | Fernando Esteves - [email protected] | Ana Cristina Mega - [email protected] | Carla Santos - [email protected] | Carmen Nóbrega - [email protected] | João Mesquita - [email protected]
Millenium, 2(1), 27-35.
Autor Correspondente Helena Vala
Estrada de Nelas, Quinta da Alagoa, Ranhados 3500-606 Viseu, Portugal
RECEBIDO: 03 de maio, 2016 ACEITE: 17 de setembro, 2016
RESUMO
Introdução: À semelhança do que ocorre na Medicina Humana, também em Medicina Veterinária, a prevalência da doença oncológica em animais de companhia tem vindo a aumentar significativamente.
Desenvolvimento: A evolução da Medicina Veterinária, nas últimas décadas, veio trazer mudança nos paradigmas clínicos, nomeadamente no respeitante à relação com o animal mas também com o proprietário. Sendo a oncologia a especialidade em que há maior probabilidade de ter que comunicar uma má notícia, neste trabalho propõe-se a adaptação do modelo ABCDE da Medicina Humana para a Medicina Veterinária.
Conclusões: A adaptação do modelo ABCDE para a Medicina Veterinária permite melhorar a comunicação com o proprietário cuidador e dotar os profissionais da equipe Médica Veterinária de melhores competências.
Palavras-chave: animais de companhia; oncologia veterinária; comunicação; má notícia; modelo ABCDE.
ABStrACt
Introduction: Similar to what occurs in Human Medicine, also in Veterinary Medicine, the prevalence of oncological diseases has significantly increased.
Development: The evolution of Veterinary Medicine, in last decades has brought changes in clinical paradigms, particularly concerning the relationship with the animal and also with the owner. More than any other specialty, members of the Veterinary Medical Team that work in the oncology field, are unavoidably forced to break bad news. This paper proposes the adaptation of the ABCDE model from Human Medicine to Veterinary Medicine.
Conclusions: The adaptation of the ABCDE model for Veterinary Medicine improves communication with the owner and offers all the members of the Veterinary Medical Team better communication skills.
Keywords: pets; veterinary oncology; communication; bad news; ABCDE model.
RESUMEN
Introducción: Similar a lo que ocurre en medicina humana, en Medicina Veterinaria la prevalencia de las enfermedades oncológicas en los animales de compañía también ha incrementado significativamente.
Desarrollo: En las últimas décadas la evolución de la Medicina Veterinaria, ha comportado cambios en los paradigmas clínicos, especialmente en la relación con el animal, pero también con el propietario. Dado que la especialidad de Oncología es la que comunica más malas noticias, en este trabajo se plantea la adaptación del modelo ABCDE de Medicina Humana a Medicina Veterinaria.
Conclusiones: La adaptación del modelo ABCDE a la Medicina Veterinaria mejora la comunicación con el propietario e proporcionará a los profesionales del equipo Medica Veterinaria de mejores competencias.
INTRODUCTION
Providing better health care and better living conditions for animals, particularly pets, along with the development of protective legislation of their rights (Lei n.º 69/2014, de 29 de agosto), has been improving substantially their quality of life, with the consequent increase on longevity, making them, similarly to their owners, a target population for geriatric diseases, including oncologic ones. Along with the evolution of Veterinary Medicine, the technical conditions of Veterinary Medical Centers (VMC) and also the skills of the veterinary team members, the oncology specialty has also evolved. Nowadays, it is possible to offer better therapeutic options, resulting not only in a better quality of life, but also in an increased survival rate. Despite all these achievements, it is important to notice, that there are also situations where patients are not candidates for definitive treatment or palliative care, being candidates to euthanasia.
Communication skills are highly valued in Humane Medicine, but neglected in Veterinary Medicine for many years. Communication is now increasingly recognized as a core skill for veterinary practitioners. The communication of an oncologic diagnosis is of great delicacy and difficulty, as many owners have had or have feared to have a personal experience with this disease (Withrow & Vail, 2007). The consequences of poor communication in the clinical field are associated with a worse clinical case management and a poorer outcome (Baile et al., 2000). It is noteworthy that the owner’s information and cooperation, only achieved with good communication skills, will contribute to prolong and improve the animal’s quality of life (Vala, 2011).
In the organization of the Veterinary Medical Team (VMT), it is now well accepted that the Veterinary Nurse (VN) can play an important role in the relation with the owner, since he detains the most privileged conditions to develop a closer relationship with him, in the agitated day-to-day clinical practice in VMC (Vala, 2016).
The adaptation of studies and knowledge, already available and developed in Human Medicine will be of great advantage in this process, thanks to its extensive, advanced and enriching experience (Hamlin, 2010).
This work analyses the importance of communication with the pet owner and addresses the basic principles of an effective, informative, frank and honest communication that can be helpful when making informed and conscious decisions. It also proposes an adaptable model to VMC day- to-day, clarifying the role of the VN, as privileged communicator, although the Veterinarian Doctor (VMD) has the greatest responsibility and the lead role in this matter. The authors suggest a modification of the ABCDE model, the one which revealed greater adaptability to Veterinary Medicine and also a model capable of improving the communication skills in every step of the evolving clinical course, in favour of the quality of health care in oncology.
1. METHODS
The research of published literature on communication models of bad news in oncology was made through bibliographic databases PubMed, Web of Science and ISI Web of knowledge, using every possible combination of these search terms: “bad news”, “oncology” and “communication”.
A lower date limit of January 01, 1999 was applied, without any upper date limit. The research included full-text articles, conference proceedings, reviews, letters, case reports or opinion articles.
An analysis and compilation of the most commonly used guidelines and models was performed, and two of them were taken in consideration: the ABCDE model (EPEC, 1999; Vandekieft, 2001; Lickerman, 2013; knott, 2015) and the SPIkES model (knott, 2015). An adaptation to Veterinary Medicine was carried out.
2. RESULTS AND DISCUSSION
The development of communication skills of the professional who deals with the oncologic pet owner, provides a real contribution to improve the quality of care. The communicator must hold technical knowledge that allows a clear and effective communication, along with perfect knowledge of the clinical evolution of the patient, comprising diagnosis, prognosis, treatment and follow up (Vala, 2016).
2.1 - Communication in the diagnosis stage
The physical condition and quality of life of the oncologic patient will suffer deterioration, more or less accentuated, depending on the type of neoplasia and the evolution of the disease. It is essential a precocious diagnosis, allowing to establish treatment as soon as possible. This will avoid the dramatic worsening of the physical condition and the maintenance of the animal’s quality of
life (Vala, 2016), minimizing the owner´s stress.
In the diagnosis stage, responsibility of the VMD, details provided by the owner about the changes in lifestyle and animal behavior, which may represent useful “signs” to reach the final diagnosis are interpretated (Vala, 2016). During the triage, the VN should also register all the aditional information that might be useful for diagnosis purposes and establishment of veterinary nursing care plans.
At this point, the VN shoul help the VMD explaining to the owner what might come next: tests; treatments; more tests and treatments; none of these options (nothing to do; euthanasia?); being this last alternative the most devastating one, only applicable in severe and terminal cases with no therapeutic alternatives (Vala, 2011 & Lickerman, 2013).
It is also essential to alert the owners for the possibility of new tumors development. The professional communicator should be able to convey the idea that the diagnosis should start at home, proceed into the VMC and that it requires more specific complementary tests (Vala, 2016).
2.2 - Communication in the prognosis stage
Despite the fact that both the establishment and communication of the outcome are the entire responsibility of the VMD, the whole VMT must know what to expect from a benign tumor, most probably a favorable prognosis, and what to expect from a malignant one, most probably an unfavorable prognosis (Vala, 2016).
Both the VMD and the VN, should be prepared for the owner´s questions, which will predictably be related with survival time. It might be wiser not to yield to the pressure and answer immediately but, instead, be prudent. Hope is very important in any stage of the process. Nothing reduces more the quality of life than living without hope. The owner will suffer more unnecessarily and its contribution for the improvement of the patient’s quality of life will be lower (Lickerman, 2013). However, it is important to keep in mind that there is a tendency to interpret any survival rate that exceeds 50%, as certain healing and any rate below 50%, as certain death (Baile, 2000).
At this stage, it is applicable the theory of expecting the best, but at the same time, prepare for the worst. The whole team should be aware that, being a serious disease, it is for the best that those who are envolved are completely aware of this fact. It is important to avoid surprises and to be able to anticipate the aggravation of the animal’s condition. It should never be forgotten that, only during the course of the disease, it will be possible to determine more precisely how the patient will react and have a better prediction of the outcome. It is advisable to recommend owners to undertake some preventive measures such as putting their affairs in order. This will allow that, in case of worsening, more availability for appointments and more preparation to apply more intensive and demanding home cares, which will make the owner and their family less vulnerable to the unexpected (EPEC, 1999).
The VMT should be able to clarify what can be realistically expected, making a clear distinction of what would effectively be desired and also of what is effectively most fearsome. If there are unexpected improvements, unpredictable according to the scientific knowledge, all the team should also be prepared to recognize it, even though these situations are rare (EPEC, 1999 & knott, 2015).
2.2.1.- the bad news communication
Bad news are the ones that alter, dramatically or only negatively, the immediate or long term future of the patient’s owner. In Human Medicine are described as examples, a terminal diagnosis, a fetal death during an ultrasound of a pregnant woman, the diagnosis of multiple sclerosis, the diagnosis of several diseases that significantly alter the patient’s life, like Parkinson’s disease and rheumatoid arthritis, among others (Vandekieft, 2001 & knott, 2015).
The response of each caregiver to bad news, also depends on the psychosocial context of the moment. It might simply be a diagnosis that comes in an inopportune moment, being described in Human Medicine the example of an unstable angina, requiring angioplasty, during the week of a daughter’s wedding, or a diagnosis that is incompatible with one’s employment, like a coarse tremor in a Cardiovascular Surgeon (Vandekieft, 2001).
In the past few decades, therapeutic advances have altered the course of cancer, being now easier to give more hope to pacients. By this reason, at the diagnosis stage, paternalistic models created by Hippocrates, defending the patient protection regarding the reality of its present condition to not discourage or depress him (Vandekieft, 2001 & Baile et al., 2000), led to the emphasis on patient autonomy and empowerment (Baile et al., 2000). This last model can also be adopted in Veterinary Medicine.
diagnosis, in order to plan the rest of their lives and make important decisions. However, other patients can not deal with the threat to their quality of life and survival time and prefer to defend themselves with “denial” or “omission”, trying to minimize the impact of the information. The author recomends that, for the few who do not want full disclosure, the delivererof the bad news should find the best way to approach the subject and must face the challenge of individualize the manner of breaking bad news, according to the patient’s desires or needs, fact that, with appropriate safeguards, can be adapted to the animal patient caregiver. The difficulty in breaking bad news is related to the huge difficulty in estimating its real impact, since it depends on the recipient’s expectations. It can also be associated with the foresight of the consequences of this communication for the owner, fear of facing the reaction of the interlocutor and with his own inability to deal with an intense emotional response, capable of causing discomfort in the sender. These reasons are often those that justify the retention of bad news, being now recognized the need to capacitate the communicator with skills to break bad news, in order to be professionally prepared to handle the shock of emotional reactions (Baile et al, 2000). Communication difficulties can lead to job dissatisfaction, higher levels of stress and to a high proportion of complaints and errors (knott, 2015).
In order to communicate, it is essential to have adequate knowledge on the subject. Besides that, a number of other factors , including fatigue, personal difficulties, behavioral beliefs and subjective attitudes, such as a personal fear of death, can affect the ability to break bad news with sensibility (knott, 2015).
The frenetic rhythm of clinical practice could also agravate the difficulties in breaking bad news and can force the VMD to deliver the bad news unexpectedly. If it is imperative to break the news, in these circumstances, the VMD should endeavor to schedule a new appointment to talk more calmly with the owner. It must avoid sounding rushed and eager to go to a scheduled task. Despite the difficult moment for the professional, it is part of another day of his work routin, but for the patient, owner and their families it is a crucial day, since their lives change to worse (knott, 2015). The VMD may not feel prepared for the intensity of delivering bad news, or may unjustifiably feel that failed with the patient. The cumulative effect of these factors is exhausting and the VN should have a complementary function, devoting more time to the owner, relieving the VMD for other demanding tasks.
Surviving members of families affected by traumatic deaths, considered important the attitude of those who gave them the bad news, regarding clarity of the message, privacy and ability to answer questions (knott, 2015).
2.2.2 - ABCDE model adaptation for Veterinary medicine
As a new way to solve an old problem, guidelines and communication models to break bad news were developed, to ensure that the information transmitted was realistic and that the bad news were delivered effectively but compassionately. This is a complex ability which goes beyond the verbal component as it requires the ability to recognize and answer to the owner´s emotions, to deal with the stress created and to be able to involve him in all decisions, maintaining some degree of hope, in a situation where the prognosis may not be favorable (knott, 2015).
The bad news must be delivered personally, never by phone, so the appointment for this purpose should be quickly scheduled. Leaving the owner anxiously waiting for news may cause a higher level of pain than the news itself. Waiting for the bad news is worse than receiving it. Once received, even if it is worse than what was feared, one can begin to deal with the problem and take action (Lickerman, 2013).
The ABCDE model, adapted from Human Medicine and proposed in the present manuscript (EPEC, 1999; Baile et al., 2000; Vandekieft, 2001; Lickerman, 2013 & knott, 2015), is the one that, in the authors opinion, better fits the Medical Veterinary multidisciplinary team, in a work context, being intuitive and easy to implement for all staff members:
A – Advanced preparation
When the communicator has limited experience in communication, he should observe a more experienced colleague, remainig discreet, in order to benefit from an excellent learning opportunity, without disturbing, since it is an intimate and complex moment between the communicator and interlocutor. The use of simulations and educational theaters are alternative methods of learning, which are useful for the preparation of Veterinary Medicine professionals before they are effectively confronted with real situations. It is appropriate at this stage that the comunicator prepares itself emotionally and professionally, knowing all the relevant clinical and scientific information, such as clinical reports, and being prepared to provide basic information about histological type of tumor, staging, biological behavior, prognosis, treatment options and survival rates. If the professional can not dominate all this information, he should seek to have it in the following appointment, researching the specialty literature or questioning experts in the field (knott, 2015). He should also possess written information for the owner to read at home, at a time of greater quietness.
It is also advisable that instead of automatically verbalizing what he is thinking, he should previously mentally rehearse the text, practicing out loud, as if he was preparing to speak in public, listing specific words and phrases to use or avoid.
It is essential to schedule the appropriate time, provide a private and comfortable place, and to instruct the rest of the team not to interrupt. Cell phones should be in silent mode or handed over to another team member. It should be taken in consideration that this will be a hard moment, so it is recommended to have facial tissues in the room and to offer a glass of water, a cup of tea, or anything else that can serve as a soothing.
B – BuIlD
This is the step in which the communicator should try to assess the owner’s preferences about the degree of truth that he really wants to know, trying to predict and anticipate a poor outcome, as this dialogue is a preparation and an opportunity to determine what the owner already knows, or what information he would actually like to acknowledge.
For this purpose, questions to determine who is the main caregiver of the patient, or to whom the test results should be transmitted, in case they determine a serious illness, should be previously planned and elaborated.
Whenever possible, it should be encouraged the presence of relatives or friends who can support the owner, if according to his will. This care reveals planning and it will be appreciated by the owner and their family members or friends.
In the first meeting, VMT must present themselves properly to everyone present, explaining what is their relationship with the patient, politely asking them to also identify and explain their relationship with the patient and the owner.
This step requires calmness, tranquility, sensibility to cultural and religious differences and personal preferences, avoiding improper mood or disrespectful/inadequate comments.
C – COMMUNICATE WELL
It is important to be factual, to inform clearly, to speak frankly but with compassion, sensibility, sympathy and empathy, avoiding euphemisms and medical jargon but not fearing the use of realistic and strong terms like “cancer” or “death”.
Several studies argue the importance of pronouncing the bad news bluntly but using anticipating expressions (e.g. I’m sorry, but I don´t bring you good news...), since starting with the negative warning, brings less emotional impact.
Also, the communicator should be aware that after receiving bad news, the owner will not retain much of what is said. It is natural that when receiving bad news, people cease to assimilate what comes next. After the bad news announcement, the person who received them does not remember half of what was explained to him. By this reason, educating and advising should be avoided at that moment and should become a concern for the following appointments. It might be useful to have relevant information written, using drawings or diagrams and repeating the key information several times.
It is recommended to take breaks, not to enter in a constant monologue and encourage questions and check if the message was understood, asking him to whether he is able to explain the situation to the rest of the family at home. It allows verifying if the owner understands the disease and also allowing him to commit himself to share his suffering with other family members. It is well known that in cases where owners want to protect others from the impact and do not share their pain, they will suffer much more. It is also at this stage that the commitment of the VMT begins, to ensure that they will always be available to support the patient and the owner.The owners must feel that someone with a position of trust, authority and specific knowledge on the subject really cares about what is happening, will not abandon them, will be actively committed to establish a care plan, will always be available to help them dealing with new issues that arise and to support them during all course of the disease, no matter what happens. It is important to ensure the availability repeatedly, given the fact that it is a very effective mean of increasing family self-esteem and confidence in the VMT. It may still be necessary, at this stage, to assure that the team will not let the patient suffer, because adequate information on pain relief provides greater security to owners. This is the greatest relief that can be provided at this stage.
D – DEAL
This step assumes that the VMD, VN and other team members are able to assess and respond to the emotional reactions of owners. Owners and their families may respond to bad news in very different ways. Some respond emotionally with tears, anger, sadness, love, anxiety, acceptance, while others feel shock, denial, guilt, unbelief, fear, sense of loss, shame or try to intellectualize
the reason of the occurrence.
Veterinary professionals, as communicators, should allow silence and tears, avoiding the urge to talk to overcome their own discomfort and being able to continue at the owner’s rhythm, giving them time to react and be prepared to support them, encourage them to describe their feelings, being in harmony with their body language. When the owner develops emotions of anger against the sender of the news, it is advisable to wait in silence, avoiding continuing to talk because, in those moments, the owner is not listening.
Understanding the news and its meaning will improve the veterinarian/owner‘s relationship, facilitating decision making and future planning.
In subsequent appointments, it is also important to monitor the emotional state of the owner, evaluating his tendency to discouragement and depression, caused by the complication that being in charge of an oncologic animal patient is, in his day-to-day life with his family and work.
Under any circumstances, the VMT should discuss or criticize co-workers, or assume defensive attitudes.
E – ENCOURAGE AND VALIDATE EMOTIONS
This step reinforces the previous ones, and also defines the ideal moment in the communicative pathway to explore the effects and meaning of the news in the caregiver, informing him of the support that he can receive. It is important to encourage hope, even if cure is not realistic, and to talk about the available options. Explaining the evolution of new oncologic treatments and talking about the frantic rhythm in which new knowledge and treatments are discovered will help. It is fundamental not to minimize the gravity of the situation, since the efforts to soften the issue, although well-intentioned, can lead to uncertainty and confusion. However, it should be remembered that usually, it is what is not said that allows people to continue to have hope, because if nothing is said to contradict it, the natural tendency of each person is to always maintain hope, even when the odds are not so favourable. Dealing with feelings of hope, avoiding to lie or to instigate false expectations, is highly delicate. On the other hand, saying that nothing can be done, ruins irreversibly the hope and can make the client look for another VMC, look for alternative ways or even opt for euthanasia earlier than necessary, since nowadays, palliative care is a reality in Veterinary Medicine.
Although inconsistent with the message of hope, if the case is really terminal, this reality should not be delayed, ignored or hidden. One way to communicate the poor prognosis is to consider the use of expressions such as “I would not be surprised if the patient died next year / month / week / day and I would prefer that everyone at home was warned and prepared”. Recognize how excellent the owner was with all the care provided to his pet along all the period, or allow him to share happy memories, can help replace the anxiety feelings associated with death.
Finnally, and in accordance with the last step of the SPIkES model (Strategy and Summary), it is important to finish the meeting with a summary and a plan for the next steps, leaving the next appointments already scheduled. There is no need to approach and decide everything at the first appointment. Whenever there is a lot of information to be transmitted, it must be repeated and clarified in the following appointments.
Necessary measures must be taken with the rest of the team, so that they are all in harmony with the planning and adopted strategy.
The follow-up, even if it is done by phone, it is a humanitarian act regarding any disease. In a serious illness, especially terminal such as oncologic disease, follow-up by phone is not enough and it requires scheduling an appointment for a week after the bad news’ communication. It is surprising the progress that some people do, a week after the announcement of the bad news. The human mind has a remarkable ability to adapt to the tragedy and begin to develop defense mechanisms right after the moment of the bad news’ transmission (Lickerman, 2013).
At the conclusion of each appointment, it is essential to commit to dedicate and strengthen the support, remembering that the team will always be present, will give full attention to the patient and will always answer the phone. Finally, accurate and easy to understand information must be disclosed, about how to have an accessible and prioritized attendance either for simple questions or for unpredictable and urgent treatments.
Table. 1. Summary of the ABCDE model adapted to Veterinary Medicine
A-ADVANCE PREPARATION
The comunicator must prepare himself emotionally and professionally Organize to have the appropriate time, with privacy and no interruptions Review the relevant clinical information
Mentally rehearse, identifying words or phrases to use and avoid B-BUILD
Determine what and how much, the owner wants to know Allow family members or friends to be present to give support Get introduced appropriately to all
Warn the owner that will communicate bad news
C-COMMUNICATE WELL
Speak frankly but compassionately; avoid euphemisms and medical jargon Use silence and body language as tools to facilitate discussion
give people time to react and allow tears, continuing at the rhythm of the interlocutors Encourage the owner to describe what he understood about the information received Allow time to answer questions; write things and provide written information
D-DEAL The whole team should be aware of how to deal with the owner, their reactions and their families E- ENCOURAgE AND VALIDATE
EMOTIONS
Assess and respond to the emotional reaction of the owner and his family
Communicate to the owner how excellent he was during the care provided to his pet STRATEgy, SUMMARy AND
PLANNINga
Finish each appointment/contact with a summary
Schedule the following appointments and follow-up plan and care
Repeat the most important information in each of the subsequent appointments aNote: this step is adapted directly from the SPIkES model
2.3 - Communication in the therapeutic and palliative care stage
The consent of the owner to establish the therapeutic care plan may constitute a contract between the client and the VMC, where economic constraints may also be a decision factor. The informed consent is a legal obligation, which requires that all the steps of treatment are properly explained, as well as potential risks (Wager, 2011).
Communication skills are vital in this step, so that the correct information is transmitted. Although the professional’s responsibility to obtain consent belongs to the VMD, the VN can also play a key role in this process (Wager, 2011). In this case, the entire team will benefit if this professional also possesses the knowledge about available treatments, benefits and costs, duration and dosage, frequency of application, mode of application and side effects (Vala, 2016).
CONCLUSIONS
1st The adaptation of the ABCDE model for Veterinary Medicine, at the various stages of evolutionary clinical course, improves communication with the owner and offers all the members of the VMT better communication skills, allowing to overcome, the difficult task that is the transmission of bad news, so common in veterinary oncology.
2º The VN is part of the team that takes care of oncologic patients and should seek to create a relationship of empathy and concern with the owner and his patient. The VN should assume himself, with respect for the other team members, as a privileged communicator in the relationship with the owner, since he has more contact with the patient.
3º The difficulties in transmitting the bad news are linked to the fact that it is an unpleasant emotional experience for both participant sides, but it also reveals itself as a reflective opportunity, in which the professional must adopt communication strategies to overcome, with professionalism, the fact that he will change irrevocably and for worse, the life of his interlocutor.
ACKNOWLEDGMENTS
This work is financed by national funds through FCT - Fundação para a Ciência e Tecnologia, I.P., under the project UID/ Multi/04016/2016. Furthermore we would like to thank the Instituto Politécnico de Viseu and CI&DETS for their support.
This work is supported by: European Investment Funds by FEDER/COMPETE/POCI– Operacional Competitiveness and Internacionalization Programme, under Project POCI-01-0145-FEDER-006958 and National Funds by FCT - Portuguese Foundation for Science and Technology, under the project UID/AgR/04033/2013.
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